The severe saddle-nose deformity may be treated by using autogenous rib cartilage (8,9).
Harvest of rib is described later. The rib graft is carved into a dorsal graft and a columellar strut, which are interdigitated to recreate an intact L-strut (Fig. 6). This type of structural re-construction is particularly useful when there is complete loss of septal support. If an intact nasal septal L-strut is present, onlay dorsal grafting will be sufficient to correct the deformity. Great care must be taken to adhere to the principle of "balanced cross-sectional carving" to minimize the risk of graft warping. Once in position, the domes can be sutured over the graft with a transdomal suture. An external rhinoplasty approach allows exposure for facile placement of these grafts. A tip graft allows improved tip projection and definition.
Figure 6. A, B: Severe saddle-nose deformity. Rib graft is fashioned into a columellar strut (secured to the medial crura) and a dorsal onlay graft that interdigitates with the columellar strut. Preoperative (C-F) photographs of a patient with a severe saddle-nose deformity. She underwent application of an iliac bone graft to her nasal dorsum in the past. Lack of an intact L-strut and in-adequate middle vault support resulted in descent of the graft, airway obstruction, and referral to our office for re-construction. Base view reveals the bone graft in the left nostril and a widened columellar scar. Graphic operative worksheet (G, H) illustrates the surgical high points. Rib graft was harvested (I, J), and exposure was achieved via the external rhinoplasty approach (K, L). A sutured-inplace columellar strut fashioned from rib graft was secured between the medial crura (M, N). A dorsal-on lay graft was carefully carved (0, P) with a notch, allowing it to interdigitate with the columellar strut. The dorsal graft was placed and se- cured (Q-T). Example from another patient illustrating interdigitation of strut and dorsal on lay graft (U). A tip graft was placed and covered with a layer of perichondrium to camouflage and soften the leading edge of the tip graft. (V, W).
When placing plumping grafts, the surgeon should overcorrect because the grafts tend to settle over time. Additionally, the pocket can be gently irrigated with antibiotic solution to minimize the incidence of infection.
When performing a caudal extension graft, the surgeon must take special care to set appropriate tip projection, rotation, length, and alar/columellar relation. Additionally, the caudal margin of the graft must be in the precise midline.
The inferior border of the caudal extension graft should be stabilized on the posterior septal angle, soft tissue, or other supporting tissues to avoid postoperative counterrotation of the extension graft.
Deviations of the caudal septum can usually be corrected by crosshatching the cartilage and other conservative maneuvers described in the text. Many cases can be corrected by accounting for excessive length of the L-strut. In rare cases, subtotal septal replacement may be necessary.
When using an integrated columellar strut/dorsal graft, the surgeon must take special care to stabilize the columellar strut in the midline to avoid shifting or tilting of the columella. Placement of the dorsal graft into a precise dorsal pocket or suture fixation of the dorsal graft to the middle nasal vault will minimize the chance of the graft shifting to one side.
Symmetric carving of the costal cartilage graft will minimize the chance of the graft warping over time.
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